商保创新药目录首次纳入医保调整方案

Core Viewpoint - The National Healthcare Security Administration has issued guidelines for the adjustment of the basic medical insurance directory and the commercial health insurance innovative drug directory, marking a significant shift in the role of commercial health insurance in the multi-tiered medical security system [1][2]. Group 1: Policy Changes - The new guidelines include the first incorporation of the commercial health insurance innovative drug directory into the adjustment scheme, indicating a major adjustment in the design logic and industry positioning of the directory [1][2]. - The commercial insurance companies will exit the price negotiation process, with the directory's nature shifting to a "recommended list," while the healthcare department will lead drug access and price confidentiality negotiations [1][2]. Group 2: Industry Participation - Pharmaceutical companies now have two pathways for submitting information for national negotiations and competitive drug pricing, akin to "filling out college applications," allowing them to choose between the medical insurance directory or the commercial insurance directory [2]. - There is a general expectation within the industry regarding the new directory, particularly as it allows companies to bypass restrictions from DRG/DIP reforms, making participation more attractive [2][4]. Group 3: Market Dynamics - The commercial health insurance market is experiencing a stabilization in growth, with 298 local health insurance products launched across various provinces as of October 31, 2024 [4]. - The participation level of commercial insurance companies may significantly influence the actual implementation of the directory, as it currently resembles a "recommended directory" without strict volume relationships [4][5]. Group 4: Support for Innovative Drugs - There is a consensus in the industry that the payment responsibility for innovative drugs is shifting from medical insurance to commercial insurance, which is seen as an inevitable trend [6]. - The 2023 measures from Shanghai aim to enhance the multi-payment mechanism to support the development of innovative drugs, indicating a broader push for integrating innovative drugs into both basic medical insurance and commercial health insurance [7]. Group 5: Future Outlook - The 2025 government work report emphasizes the need to deepen medical insurance payment reforms and support the development of innovative drugs, highlighting the potential for commercial insurance to play a larger role in this area [8]. - The commercial health insurance sector currently contributes only 7.7% to the payment for innovative drugs, indicating significant room for growth as demand for specialized medical services increases [8].